Healthcare Provider Details

I. General information

NPI: 1518273911
Provider Name (Legal Business Name): PERFORMANCE HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 REAVIS BARRACKS RD
SAINT LOUIS MO
63125-2438
US

IV. Provider business mailing address

3641 REAVIS BARRACKS RD
SAINT LOUIS MO
63125-2438
US

V. Phone/Fax

Practice location:
  • Phone: 636-219-9664
  • Fax:
Mailing address:
  • Phone: 636-219-9664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038011404
License Number StateMO

VIII. Authorized Official

Name: MRS. MIRANDA LEIGH DAVIS
Title or Position: PROPRIETOR
Credential:
Phone: 636-219-9664